Peripapillary choroidal neovascularization (PCNV) can result in significant vision loss due to extension of blood or fluid into the macula.1,2 Treatment options for PCNV have included laser photocoagulation, subretinal surgery, and photodynamic therapy.1,3,4 More recently, the use of intravitreal anti–vascular endothelial growth factor antibodies has emerged as the optimal treatment for macular CNV due to age-related macular degeneration, presumed ocular histoplasmosis, myopia, angioid streaks, and traumatic choroidal rupture,5,6 but clinical trials almost exclusively included patients with subfoveal CNV. The purpose of this study was to review cases of PCNV treated with intravitreal bevacizumab.

METHODS

Institutional review board approval was obtained. The Institutional Review Board for Human Subjects Research, University of Iowa, waived informed consent for this retrospective record study. The study was compliant with the Health Insurance Portability and Accountability Act of 1996 and adhered to the tenets of the Declaration of Helsinki. Data from records of patients who received 1.25-mg intravitreal bevacizumab injections at the University of Iowa between September 12, 2008, and March 21, 2011, were retrospectively reviewed. Patients were included if they demonstrated a new, previously untreated PCNV confirmed by fluorescein angiography and subretinal or intraretinal fluid on optical coherence tomography (OCT) and had at least 6 months of follow-up. Patients with vision loss from other non-PCNV causes were excluded. Resolution of PCNV was determined by the absence of intraretinal or subretinal fluid on examination and OCT. Recurrence was defined as new subretinal or intraretinal fluid detected by OCT or hemorrhage detected by ophthalmoscopy.

RESULTS

Twenty eyes from 19 patients met the inclusion criteria. The average patient age was 70.6 years (range, 26-94 years). Causes of PCNV included AMD in 12 eyes, presumed ocular histoplasmosis in 6 eyes, traumatic choroidal rupture in 1 eye, and idiopathic PCNV in 1 eye. Fifteen of 20 eyes had peripapillary fluid on OCT within 1 disc area from the disc without any subfoveal fluid. Only 5 eyes had subfoveal fluid (Table). Sixteen had peripapillary fluid located temporal to the optic nerve, 3 had it located superiorly, and 1 had it located inferiorly. The follow-up averaged 13.5 months (range, 6-32 months).

An average of 5.6 total injections (range, 2-14 injections) were performed (Figure). Complete resolution of intraretinal and subretinal fluid on OCT was achieved in 17 of 20 eyes (85%) after an average of 2.4 intravitreal injections (range, 1-5 intravitreal injections) (Figure). Subsequently, there were an average of 2.7 injections (range, 0-10 injections) (Figure). Although some of these were given for maintenance therapy, 5 of 17 eyes developed recurrent fluid on OCT at an average of 8.3 months following the last injection (range, 4.5-15 months). The recurrent cases included 4 eyes with AMD and 1 eye with presumed ocular histoplasmosis (Figure). The fluid did not resolve completely in 3 of 20 eyes (15%). Six of 8 non-AMD cases remained dry after treatment throughout follow-up (Figure).

Figure. Treatment and response to intravitreal bevacizumab in 20 eyes with peripapillary choroidal neovascularization. A, Peripapillary choroidal neovascularization was diagnosed in 12 eyes with age-related macular degeneration (AMD). B, Peripapillary choroidal neovascularization was diagnosed in 8 non-AMD eyes, including 6 with presumed ocular histoplasmosis (POHS), 1 with trauma, and 1 with idiopathic cause. Resolution of fluid is indicated. The number of injections given at 4- to 6-week intervals that were required to achieve resolution of fluid on optical coherence tomography is shown to the left of where resolution is indicated. The number of injections following resolution of fluid is shown to the right of where resolution is indicated. Periods of fluid remission and recurrent fluid are shown. *Four patients had follow-up for longer than 12 months. †Three patients did not achieve fluid resolution at their last follow-up visit.

The preinjection visual acuity averaged 20/40 (range, 20/20-20/100). The postinjection visual acuity averaged 20/30 (range, 20/15-20/60). In eyes with sustained fluid or recurrent fluid, vision at the final follow-up examination remained stable compared with their baseline visual acuity. Of the 112 total injections given, there were no adverse events related to treatment.

COMMENT

In our study, 17 of 20 eyes (85%) achieved resolution of the fluid after an average of 2.4 intravitreal injections of bevacizumab, and 5 of these had recurrent fluid. Visual acuities improved by an average of 5 letters or 1 line of Snellen visual acuity after an average of 13.5 months of follow-up, and only 1 patient lost vision limited to 1 line (Table).

Overall, it is our impression that PCNV responds to intravitreal bevacizumab with reduction of retinal fluid and improvement or preservation of vision comparable to other treatment modalities.1 However, our results are limited by the relatively short term of the study. In PCNV cases of recurrent or incomplete fluid resolution, intravitreal bevacizumab may still shrink lesions prior to other treatment. Further prospective and comparative studies are required to better understand the risks, benefits, and limits of this therapeutic modality.

Figures

Figure. Treatment and response to intravitreal bevacizumab in 20 eyes with peripapillary choroidal neovascularization. A, Peripapillary choroidal neovascularization was diagnosed in 12 eyes with age-related macular degeneration (AMD). B, Peripapillary choroidal neovascularization was diagnosed in 8 non-AMD eyes, including 6 with presumed ocular histoplasmosis (POHS), 1 with trauma, and 1 with idiopathic cause. Resolution of fluid is indicated. The number of injections given at 4- to 6-week intervals that were required to achieve resolution of fluid on optical coherence tomography is shown to the left of where resolution is indicated. The number of injections following resolution of fluid is shown to the right of where resolution is indicated. Periods of fluid remission and recurrent fluid are shown. *Four patients had follow-up for longer than 12 months. †Three patients did not achieve fluid resolution at their last follow-up visit.

Correspondence

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